Medicaid coverage, state by state

UnitedHealthcare calls its weight-loss program "an optional program that is put in place for clients or businesses that have elected to cover weight loss products". If your employer did not elect it, there is nothing to prior-authorize.

• Wegovy injection, tablet and HD Covered, prior authorization

  Only where the employer bought the benefit. BMI of 30 or over, or 27 or over with a weight-related condition, plus lifestyle changes alongside it. First approval runs 5 months.

• Zepbound Covered, prior authorization

  Only where the employer bought the benefit. Same BMI test. First approval runs 6 months. Zepbound is also reachable for moderate to severe sleep apnea on plans with no weight-loss cover at all.

• Foundayo Covered, prior authorization

  Foundayo is on the same program as the injections, with the same BMI test. First approval runs 6 months.

Covered by state mandate regardless: California, New Mexico, North Dakota, New York.

North Dakota fully insured Essential Health Benefit plans are much stricter than the standard program: they require a BMI of 40 or over.

CVS Caremark is a pharmacy benefit manager, so it publishes template formularies that employers may adopt. It states that "plan sponsors that adopt CVS Caremark template formularies retain discretion to customize coverage for their members", and describes the Zepbound change as applying "for plan sponsors who elect to provide coverage".

• Wegovy injection and tablet Covered

  Wegovy has been the preferred GLP-1 for weight management on the template formularies since 2025, in both injection and tablet form.

• Zepbound Covered

  Returning to the commercial formularies as an additional preferred option on 1 October 2026, after being dropped in May 2025 in favor of Wegovy. Before that date, plans following the template formulary do not cover it.

• Foundayo Covered, prior authorization

  The new-to-market block on Foundayo was removed on 1 June 2026, "where approved for coverage by plans".

Caremark is the benefit manager rather than the insurer, so the same formulary sits behind plans sold under several different insurer brands, including Aetna.

This is one national plan rather than thousands of employer designs, so its published policy is the answer. It sets the rules itself and prints them.

• Zepbound Covered, prior authorization

  BMI of 30 or over, or 27 or over with established cardiovascular disease or a weight-related condition. 🔴 You also have to have already tried at least two oral weight-management medicines, such as phentermine or Qsymia, and failed or not tolerated them, and to have taken part in a weight management program.

• Wegovy, Saxenda Not checked

  Governed by a separate policy from Zepbound, which nobody here has opened yet. We are not going to assume it matches.

The separate policy covering the older non-GLP-1 weight-loss drugs adds a general stopping rule: if your BMI has not fallen appropriately after 12 to 16 weeks, the medicine is discontinued.

Aetna states it plainly: "Many Aetna plan benefit descriptions specifically exclude services and supplies for or related to treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications... will be denied based on that exclusion." So the first thing to read is your own plan document, not Aetna’s criteria.

• Wegovy Covered, prior authorization

  Where the plan covers it at all: 18 or over, BMI of 30 or over, or 27 or over with a weight-related condition. 🔴 And the hardest requirement any payer here sets, which is that you must already have taken part in a weight management program with follow-up for at least six months BEFORE starting the drug.

• Zepbound Not checked

  Governed by its own pharmacy bulletin, which nobody here has opened. We are not going to assume it matches the Wegovy one.

Aetna is owned by CVS Health, so the CVS Caremark formulary above often sits behind an Aetna plan. They are two different decisions: the formulary says which drug is preferred, the benefit design says whether weight-loss drugs are covered at all.

Cigna writes into the policy itself that a customer’s benefit plan document "always supersedes the information in the Coverage Policies", and that "benefits are ultimately determined by the terms of the applicable benefit plan document". The criteria below decide nothing if the employer never bought weight-loss cover.

• Wegovy injection, tablet and HD Covered, prior authorization

  Only where the plan includes a weight-loss drug benefit. Cigna also runs a separate cardiovascular route at a BMI of 27 or over for adults 45 and over, which does not depend on weight-loss cover.

• Zepbound Covered, prior authorization

  Only where the plan includes a weight-loss drug benefit. Sleep apnea is a separate route, at a BMI of 30 or over with a confirmed apnea-hypopnea index.

• Saxenda Covered, prior authorization

  Only where the plan includes a weight-loss drug benefit. For children, Cigna applies a 1% BMI reduction test after 12 weeks on the maintenance dose.

Cigna publishes the clinical criteria and the disclaimer in the same document, which is unusually honest: the policy tells you what the rules are and then tells you the plan document beats them.

Kaiser puts it above every clinical test: Zepbound is covered for weight loss "ONLY for Kaiser Northwest members with coverage for medications used to treat weight loss. Others pay member cash price." The first criterion in the list is having the benefit at all.

• Zepbound Covered, prior authorization

  Non-formulary, so it needs a clinical review. Adults 18 and over, weight and BMI documented in the last 30 days, no personal or family history of medullary thyroid carcinoma or MEN 2. Approval runs 12 months.

• Wegovy Not checked

  Kaiser publishes criteria per drug and per region. The Wegovy document was not read, and a Zepbound policy does not answer for Wegovy.

Kaiser is integrated, so the health plan and the pharmacy are one organization and the criteria are its own rather than a pharmacy benefit manager’s. It runs eight regions with separate committees. What is recorded here is the Northwest region, and it does not answer for the others.

A national formulary is the starting point a plan sponsor may then customize, so being on this list is necessary and not sufficient. The document says so itself: it "is not all-inclusive and does not guarantee coverage".

• Wegovy pens, tablets and HD Covered

  All three presentations are on the 2026 national preferred formulary. Being listed is not the same as your plan having bought weight-loss cover.

• Zepbound pen Covered

  The pen is on the 2026 national preferred formulary. The vial is not named anywhere in the document, and the document says it is not all-inclusive, so that is not a published exclusion.

• Saxenda Not checked

  Not named in the abbreviated formulary, which states it lists only the most commonly prescribed medicines. That is absence, not exclusion.

Express Scripts publishes an abbreviated national formulary and a separate exclusions list. Wegovy in all three presentations and the Zepbound pen are on the covered list for 2026. The document limits itself in its own words, so nothing here should be read as a promise about a particular employer’s plan.

Optum Rx marks all three weight-loss GLP-1s "++" on the formulary itself, which its legend defines as "Benefit design options. Coverage is determined by your prescription medication benefit plan." The drug is listed and the plan still decides.

• Wegovy Covered, prior authorization

  Tier 2 on the 2026 Select Standard formulary, with prior authorization, a quantity limit, and the benefit-design marker.

• Zepbound Covered, prior authorization

  Tier 2 on the same formulary, with prior authorization and a quantity limit.

• Saxenda Covered, prior authorization

  Tier 2, with prior authorization, a quantity limit, and the benefit-design marker.

Optum Rx publishes several formularies and this is the Select Standard one. A plan sponsor may use a different list, so being here is the starting point rather than the answer.